F0658

D

Failure to Implement Physician Order for APP Mattress for At-Risk Resident

Clearlake, California Survey Completed on 02-24-2026

Penalty

No penalty information released

Summary

The facility failed to ensure services met professional standards of quality when a physician’s order for an alternating pressure pad (APP) mattress was not implemented for one resident. The resident was admitted in January 2026 with diagnoses including unsteadiness in feet and dysphagia. A physician’s order dated 1/16/26 directed that an APP mattress be placed on the resident’s bed. On 2/20/26, a licensed nurse stated that physician orders should be followed and that if an APP mattress was ordered, the facility should provide it; the nurse acknowledged that failure to follow the order meant facility policy was not followed and that residents would be at risk for further skin issues. During an observation in the resident’s room that same day, another licensed nurse confirmed the resident was on a regular mattress and not on an APP mattress, and stated the resident had fragile skin and was at risk for developing pressure ulcers.

In a concurrent interview and record review with the ADON on 2/20/26, the ADON verified that the resident was not on an APP mattress despite the active physician order from 1/16/26. The ADON also confirmed the resident’s Braden score was 15, indicating the resident was at risk for pressure ulcers, and stated that using an APP mattress was a preventive measure to help prevent development of pressure ulcers. The facility’s policies indicated that appropriate support surfaces should be selected based on residents’ risk factors in accordance with current clinical practice, that medications are administered in accordance with prescribers’ orders, and that staff must demonstrate skills necessary to care for residents’ needs including skin and wound care. A policy specific to physician orders was requested but not provided.